Seen at Maternity HDU/Emergency
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PATIENCE NUNOO
32years
35WKS + 2D
G3P1 +1SA( 1 PREVIOUS CS)
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PC: REFRAL O/A PLACENTA ABRUPTON
HPC: Client was well until FEW HOURS PRIOR TO PRESENTATION WHEN SHE NOTICED SPOTTING, DARK IN COLOR, THAT INCREASED GRADUALLY AFTER.
ODQ: , +LAP, +BPV, -dizziness, -palpitation, -fevers, -headache, -BURRED VISION,-vaginal discharge, -dysuria
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PMS Hx: Nil of note
DHx: FOLIC ACID, VIT C, IRON
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Obs HistorY
1ST PREGNANCY
UNPLANNED, SPONTANEOUS ABORTION WITH NO COMPLICATIONS AFTER
2ND PREGNANCY
UNPLANNED, BUT WELCOMED, DELIVERED VIA CS, NO COMPLICATION
Index Pregnancy
UNPLANNED BUT WELCOMED, Booking LABS DONE
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Gynae Hx
Cycle: 5/26, 3pads per day, +dysmenorrhoea,
history of pap smear DONE, NO breast screening
No history of PID or STI
Lifetime partners- 1
Family Hx: unremarkable
Soc Hx: Lives at ACCRA, TRADER, accepts transfusion, -smoke, -alcohol use,
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On Examination
Young WOMAN, STABLE AND WELL LOOKING, afebrile, no conjunctival pallor, no pedal oedema, hydration fair
CVS: . Radial pulse-rgv. +S1. +S2. -M0
RS: RR 20cpm. SPO2 97% ora. Breath sounds-vesicular, no crepitation
ABD: Gravid uterus. TENDERNESS, SFH; 36cm, fhr; 142bpm
CNS: Conscious and alert. Grossly intact. GCS 15/15
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Impression
gravid
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Plan
– to do emergency cs
– FBC, BUE, LFT
